Provider Demographics
NPI:1417790726
Name:MIRKHANI, OMID (DMD)
Entity type:Individual
Prefix:
First Name:OMID
Middle Name:
Last Name:MIRKHANI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-2513
Mailing Address - Country:US
Mailing Address - Phone:630-628-3115
Mailing Address - Fax:
Practice Address - Street 1:200 W LAKE ST
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2513
Practice Address - Country:US
Practice Address - Phone:619-906-0376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.035375122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist